Rhinitis Types

Allergic rhinitis (AR)	Seasonal (SAR) Perennial (PAR) Episodic Local (LAR) characterized by local production of sIgE, a TH2 pattern of mucosal cell infiltration during allergen exposure, and positive response to nasal specific allergen provocation test (NAPT) manifested by symptoms and increased levels of sIgE, tryptase, and ECP in nasal secretions Note: Patient may have AR to aeroallergens that were not tested for (eg, uncommon molds) False negative allergen testing may also erroneously rule out AR AR may develop by 18 months old in 9% of children (rhinitis symptoms apart from colds associated with atopic family history, eosinophilia >470/mm3, and sensitization to aeroallergens, especially dust mite) Tree pollen sensitivity (via SPT) found in 13% of children <4 yo in one study in the US Northeast
Nonallergic rhinitis (NAR)	Vasomotor rhinitis (VMR) Irritant triggered (eg, smoke, perfume, cleaning products) Change in temperature/humidity (eg, cold air) Exercise (eg, running) Undetermined or poorly defined triggers Gustatory rhinitis - cholinergically mediated syndrome of watery rhinorrhea occurring immediately after ingestion of hot and spicy foods Infectious Viral URI Bacterial, fungal rhinosinusitis NARES - nonallergic rhinitis with eosinophilia syndrome Typically middle age adults with perennial nasal symptoms (particularly nasal congestion), sneezing, watery rhinorrhea, nasal pruritus, occasional loss of smell, risk for OSA Nasal smear eos >5-20%, no evidence of allergic sensitization by SPT or sIgE (?local IgE production), total IgE usually normal, about half without asthma have increased airway hyperreactivity
Occupational rhinitis (chemical/irritant)	Caused by protein and chemical allergens; IgE mediated Caused by chemical respiratory sensitizers; immune mechanism uncertain Work-aggravated rhinitis
Hormone-induced	Pregnancy rhinitis de novo - nasal congestion due to hormone induced vasodilation, usually starts in 2nd or 3rd trimester and resolves 2 weeks post delivery 1/3 of pregnant women with pre-existing AR have worsened symptoms during pregnancy Nasal steroids not effective Breast-feeding Menstrual cycle related Oral contraceptives Hypothyroidism - turbinate edema due to elevated TSH, symptoms usually nasal congestion but can include rhinorrhea Often mentioned in reviews of NAR but supportive evidence is not strong Acromegaly - often mentioned in reviews of NAR but supportive evidence is not strong
Drug-induced	Oral contraceptives Rhinitis medicamentosa Discontinuation of topical vasoconstrictors (oxymetazoline, cocaine, neosynephrine) after prolonged use (>5-7 days) resulting in rebound nasal congestion and reduced mucociliary clearance due to loss of ciliated epithelial cells Cocaine abuse should be suspected if presenting with frequent nosebleeds, crusting, and scabbing Antihypertensive and cardiovascular agents ACEI rhinitis (may develop in absence of cough) Beta-blockers (even ocular) Alpha-blockers (e.g., prazosin, terazosin) Phosphodiesterase-5–selective inhibitors (eg, sildenafil, vardenafil) Calcium channel blockers Aspirin/NSAIDs - isolated rhinorrhea without AERD Some antidepressants, benzodiazepines, psychotropics, and antiepileptics (e.g. chlordiazepoxide, amitriptyline, chlorpromazine, risperidone, thioridazine, gabapentin) AERD Alcohol ingestion - possible ALDH deficiency (Asian flush), sulfite sensitivity, histamine intolerance, IgE-mediated reaction to allergen in drink (e.g. barley), alcohol sensitivity due to CRS with nasal polyps Psychiatric Risperidone Amitryptiline
Rhinitis associated with inflammatory-immunologic disorders	Granulomatous infections Wegener granulomatosis Sarcoidosis Midline granuloma Churg-Strauss syndrome Relapsing polychondritis Amyloidosis
Atrophic rhinitis	Primary atrophic rhinitis Progressive atrophy of turbinates, nasal mucosa, and underlying bone, with nasal dryness, foul-smelling nasal crusts; often associated with sinusitis and may have infectious basis Associated with Klebsiella ozaenae Occurs more commonly in young to middle-aged adults living in arid climates Nasal cavities appear wide open on examination but is paradoxically perceived as severe nasal congestion. Secondary atrophic rhinitis Less severe and progressive than primary, develops as a result of other conditions, such as chronic granulomatous nasal infections, chronic sinusitis, excessive nasal surgery, trauma, and irradiation

Note: 44-87% may have mixed rhinitis (a combination of allergic and non-allergic rhinitis)

Differential Diagnosis

Conditions that might mimic symptoms of rhinitis

• Nasal Polyps
• Sructural/mechanical factors
  • Deviated septum/septal wall anomalies
  • Adenoidal hypertrophy
  • Trauma
  • Foreign body
  • Nasal tumors
    • Benign
    • Malignant
  • Choanal atresia
  • Cleft palate
  • Phayngonasal reflux
  • Acromegaly (excess growth hormone)
• CSF rhinorrhea
• Ciliary dyskinesia syndrome
• CF

Classifying Severity (ARIA)

Frequency	Severity
Intermittent	Mild
<4 days per week OR <4 consecutive weeks	All of the following: Normal sleep No impairment of daily activities, sport, leisure---------- No impairment of work and school Symptoms present but not troublesome
Persistent	Moderate-severe
>4 consecutive weeks---------- AND >4 days/week	One or more of the following: Sleep disturbance Impairment of daily activities, sport, leisure Impairment of school or work Troublesome symptoms

Treatment

References